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Dear Friends,
As we enter the beginning of August and the start of the school year, the fervor and urgency around being able to safely reopen our communities has grown tremendously. As you will read below, the lack of vaccine or effective treatments for COVID-19 means that, above all else, the best way to handle the disease is to keep it from spreading.
Penn Medicine has been working directly with the City of Philadelphia on contact tracing, and the importance of those efforts cannot be overstated. For that reason, I’m thrilled to introduce Kevin Volpp, MD, PhD, and Carolyn Cannuscio, ScD. Dr. Volpp is the Founders President’s Distinguished Professor of Medicine and Medical Ethics and Policy and the Founding Director of the Center for Health Incentives and Behavioral Economics. Dr. Cannuscio is Associate Professor of Family Medicine and Community Health and Director of Research for the Center for Public Health Initiatives. Together, they have been leading an innovative and effective contact tracing program that combines traditional methods with novel digital strategies.
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Let’s start with the basics: What is contact tracing, and how does it help reduce transmission of a virus?
KV: Contact tracing is a time-honored approach utilized across many previous infectious disease epidemics.
CC: Exactly — it’s the cornerstone of a comprehensive prevention approach for any communicable disease.
When someone tests positively, we call them and ask about their locations, behaviors, and face-to-face encounters in the two days prior to when they became symptomatic (or got tested); we ask where they think they might have gotten infected; and, importantly, we reach out to individuals who patients tell us they’ve been in close contact with.
We then try to figure out a way to help all of them adhere to prevention measures. Keeping our distance is the most effective prevention strategy we have right now.
KV: It’s about interrupting the chain of transmission.
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Does contact tracing for COVID-19 differ in any way from contact tracing for other viruses?
KV: Contact tracing is more challenging for COVID-19 than it is for many other viruses, and much of it has to do with isolation. So keep in mind that the incubation period range is long — which is why the recommended quarantine period is 14 days.
Because early treatment for the disease does not have clear benefits, we’re asking contacts to quarantine themselves primarily to protect others. Now, because the virus is so transmissible, we’re even asking cases to isolate from members of their own household; that’s an extremely difficult ask, especially in apartments. Finally, because asymptomatic and pre-symptomatic transmission is possible, we are asking contacts to adhere to quarantine even without the “cue” of feeling unwell.
CC: And with regard to the contact tracing itself, one thing that’s very different is we’re not going door-to-door —it’s challenging to build relationships over the phone.
Another huge difference is that sheer scale of these efforts is unprecedented. Many of our contact tracers went straight from “learning” to “doing” right away, and that hasn’t ever really happened before at this scale.
KV: As Carolyn has noted elsewhere, for someone living paycheck-to-paycheck, missing work for two weeks even though you feel perfectly fine is immensely difficult.
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How critical is contact tracing as we seek to safely reopen our cities and relax our social distancing protocols?
KV: It’s extremely critical. Until we develop a vaccine or significantly more effective treatments for this disease, the only way of reducing risk is through the “Test, Trace, Isolate” strategy and adherence to physical distancing.
CC: And we need to think of contact tracing as part of a much larger, comprehensive approach. The efficacy of “Test, Trace, Isolate” hinges upon a functioning system.
It requires large-scale testing, and the ability to get those test results rapidly. If tests aren’t available or results are delayed, those people have opportunities to infect others — and then we can’t reopen our cities or relax social distancing.
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How long might contact tracing be necessary?
KV: As long as we have cases of COVID-19. Nobody really knows how long that might be.
CC: COVID-19 will be with us even after we have a vaccine. It could just become like other reportable or notifiable diseases, but I don’t think it’s going away.
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How did Penn get involved with contact tracing efforts in Philadelphia? What has the partnership with the Philadelphia Department of Public Health entailed, and how has it helped accelerate this work?
KV: The Center for Health Incentives and Behavioral Economics (CHIBE) has been involved in efforts to improve the health of populations throughout the country in a variety of different clinical contexts, so we are always looking to step in where help is needed. The rapid emergence of the COVID-19 epidemic, coupled with a lack of personnel and resources at the city level, meant we felt the need to get involved.
Dr. Cannuscio’s team was the first to help provide contact tracing in the City of Philadelphia.
CC: The Center for Public Health Initiatives (CPHI) was approached and asked how we could help. The demands on time and resources made it extremely difficult for the City to train enough contact tracers, so we decided to take that on, develop a training program, and work alongside the Health Department.
Within a week of those first conversations, we had reached out and recruited about 100 volunteers. Many of them were Masters of Public Health, social work, or nursing students. A few weeks later, graduate students had taken the lead. We built the whole thing from scratch.
Penn’s contact tracing team is now the only academic partner doing contact tracing with the City. So far, they have hired 80 contact tracers full-time —including a number from our program — and our strongest team members have gone on to leadership roles in that operation. We’re proud of them, grateful for their service, and thankful for our strong, ongoing relationship with the City.
Also, our workflows have evolved together to incorporate the challenges we face, the problems we are solving, best practices, shared training materials, the collection of data, and so much more.
Simply put, we couldn’t do this without the partnership of the health department. It’s one I hope will last long after the COVID-19 crisis is over, so we can continue to work together.
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Your approach to contact tracing has been described as “multi-pronged,” featuring traditional methods as well as innovative digital strategies. Can you explain that approach, and what benefits it will have over traditional contact tracing alone?
KV: Traditional contact tracing can be quite effective — but as we noted earlier, there is a higher degree of difficulty with COVID-19, given the large population of people who are asymptomatic and may not even know they are infected.
CC: We’re trying to address the pain points in the traditional process through digital tools. If I were to ask you, “Okay, tell me everyone you were in contact with last week on Friday or Saturday,” that might be an extremely difficult question to answer — especially when we have so many people living through this pandemic right now routinely saying they don’t know what day it is.
Our normal schedules and behaviors have been upended, and so the idea is, through Bluetooth proximity tracking and other apps, we can augment those faulty memories with digital tools to see who truly had meaningful contact.
KV: Our team has also established PennOpen Pass, a system for digital recording of symptoms that students, faculty, and staff are expected to participate in on a daily basis as an early-warning system for any concerning signs. As soon as those symptoms are reported, our system for testing and contact tracing can be initiated. We are also using it to regulate building access to reduce risk of exposure within Penn buildings.
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What are some of the more complex issues that need to be navigated by contact tracing teams? How are contact tracing teams perceived by the public and how do contact tracers try to build community trust?
CC: I think there’s a narrative taking root that the American public is resistant to contact tracing, and I’m dispirited by it. When we first started this work, we built our team with input from Student Health Services, and they told us — and it has been our experience from the very start — that you’d be surprised how grateful people are for your call.
People appreciate the calls, they appreciate the information, they appreciate the clarification of how to follow through with isolation and quarantine. These calls aren’t just an effort to extract information, they’re an effort to provide information, and people really get that.
We’re also dealing with sensitive information in an era of collective trauma and heightened stress. This is an exceedingly difficult time, especially for the Black communities — because not only does COVID-19 impact the Black community more severely, but also all of this is occurring in the middle of a necessary, painful, nationwide reckoning with systemic racism. Obviously here in Philadelphia, where such a large proportion of our community is Black, we have had to keep that profound stress front-of-mind.
I think one important factor in public trust for our group has been that we have one phone number, and it comes up as “Penn Medicine” on caller ID. It helps us be seen immediately as an extension of the Penn Medicine team, with a long-standing reputation for quality care. It gets through about 80% of the time, which is a high success rate compared to other teams around the country.
Also, our volunteers have been trained in trauma-informed interviewing, making them better at listening and getting to the heart of the challenges facing the people on the other end of the phone. It takes emotional intelligence, skill, and practice. Our program has a social needs screener, through which we ask people if they’re having difficulty getting food, paying rent, meeting childcare needs, or dealing with mental health issues.
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Is it possible to translate our contact tracing approaches to other areas? Do you foresee these digital strategies being the future of contact tracing?
CC: There is an endless number of things we are learning and can apply. Through rapid-cycle experimentation, we can develop more effective strategies and then disseminate those across other arenas. Behavioral science research that determines how to better get people to adhere to prevention behaviors or get tested sooner can be carried over. It helps us learn what is necessary to assist people in choosing healthy behaviors.
KV: Digital strategies are best used as a complement to manual contact tracers. For example, digital contact tracing systems cannot tell whether an individual was wearing a mask or engaged in other risk mitigation efforts that might lower the risk of close contact.
CC: There absolutely has to be human support. Especially in a time of great stress and a flood of information, people need access to helpful guidance. There is no replacement for the care, concern, and provision of information from a human being.
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I would like to thank Drs. Volpp and Cannuscio for taking the time to answer these important questions and sharing some remarkable insights into the vital work of contact tracing.
And thank you, friends and partners of Penn Medicine, for your continued interest and support of the work being done here. As you read above, much of our contact tracing efforts rely on volunteer work, but support can help bolster that infrastructure significantly — and support research on making both digital and manual efforts to reduce COVID risk more effective, research that can be shared to improve the effectiveness of programs across the United States.
For example: If we continue with a volunteer staffing model, we need support for leads or managers who can recruit, train, and oversee the day-to-day work of the volunteer contact tracers. Research dollars can fuel projects to understand the forces that motivate people to adhere to precautions and get tested in a timely manner, as well as support the creation of models that can be used throughout the country.
Gifts can also help our research assistants — who are getting excellent public health training opportunities — to secure mentorship, be involved in publications, and make a real impact on public health this very minute. As Dr. Cannuscio has shared with me, one thing we have absolutely learned is we need a more robust public health infrastructure in this country. What better way to do that than by training the next generation?
To support the Penn Medicine Contact Tracing Fund, click here. Learn more about Penn Medicine’s other COVID-19 priorities here. And as always, please visit pennmedicine.org/coronavirus for the latest information about visitation policies, patient appointments, drive-through testing sites, and more. You can also call our toll-free coronavirus hotline at (833)-983-1350.
Sincerely,
Jonathan A. Epstein, MD
William Wikoff Smith Professor of Cardiovascular Research
Executive Vice Dean and Chief Scientific Officer, Perelman School of Medicine
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